ACCF/AHA release updated guidelines for patients with HF

The targeted update includes a new section for the management of acute decompensated HF.

The American College of Cardiology Foundation and American Heart Association have released a focused update to their guidelines for the management of HF in adults.

In an effort to respond quickly and to incorporate new published data into recommendations, a focused update by the ACCF/AHA Task Force on Practice Guidelines was added to the document, which was written in 2005.

The updated guidelines include an entirely new section of recommendations for the management of patients hospitalized with acute HF. The Task Force also added clarifications on several recommendations and changed language in others to make them consistent with current evidence and other therapeutic guidelines. Several outdated recommendations made in the 2005 guidelines were removed.

Some of the other changes included the addition of a strong recommendation for the use of hydralazine and nitrates to reduce outcomes in patients self-described as black. Evidence for a Class III recommendation against the intermittent infusions of positive inotropic agents for patients with refractory end-stage HF was upgraded from Level B to Level A.

Jessup M. Circulation. 2009;doi:10.1161/CIRCULATIONAHA.109.192064.

Each year, the AHA and ACC review all of the published, presented major trials and other information that might conceivably change the recommendations for any specific guideline. That process has been ongoing for the HF guidelines. This year, we felt that enough had changed to warrant an update.

However, we broke all kinds of rules this year because typically updates do not have new sections. The writing committee felt that the management of acute HF was so important and so current that a whole new section was added to the guidelines about the hospitalized patient. It just turns out that most of the more recent trials were also done in patients with acute decompensated HF.

Outside the hospitalized patient section, the major changes were to comment on the strategy of managing patients with HF and atrial fibrillation. The results of a couple of new trials have been published but neither pointed to an advantage of one strategy over another, with the two strategies being controlled ventricular response vs. maintaining sinus rhythm. Our recommendation really did not change, but there was more information saying that there is no advantage in general of one strategy over the other.

The second recommendation that changed was a strengthening of our assertion to use hydralazine isosorbide dinitrate in blacks, because the findings of the A-HeFT trial had been published just about when the guidelines of 2005 were completed. This really strengthens that assertion, based on the 40% reduction in mortality in the A-HeFT trial. We strongly urged the hydralazine isosorbide to be used in addition to standard medical therapy in blacks.

The third thing that changed was really a simplification of the recommendations about when to use and think about implantable cardioverter defibrillators. The [recommendations] were simplified to be concordant with the guidelines that were put out about the management of ventricular arrhythmia.

In the hospitalization section, we covered many things about looking for the etiology of decompensated HF; what to do about medicine reconciliation and initiating drug therapy; the role of hemodynamic assessment in the hospitalized patient; the role of inotropes in the hospitalized patient; but probably most importantly, what has to happen in the transition between discharge from the hospital and patients going home.

Many insurance companies and governmental agencies are looking carefully at that transition because the rate of readmission for HF is very high. In fact, when we were at the ACC meeting they announced a big initiative called the H2H (Hospital to Home) initiative, and the AHA and Joint Commissions also have an initiative to look at HF and proven quality of care. Many people are interested in what happens to the patient who is hospitalized with HF and what happens to them when they go home, and we therefore felt that it was important to begin to outline guidelines.

– Mariell Jessup, MD

Professor of Medicine, University of Pennsylvania School of Medicine

The update streamlines things very nicely with respect to defibrillators and cardiac resynchronization devices. Perhaps more important is the new section addressing the sometimes contentious issue of best management practices for the hospitalized patient with acutely decompensated HF. Less solid evidence is available for “best treatment practices” in that group of individuals.

– James B. Young, MD

Cardiology Today Section Editor